Methods Of Treating Fabry Disease In Patients Having The G9331A Mutation In The GLA Gene

ABSTRACT

Provided are methods of treating a patient diagnosed with Fabry disease and methods of enhancing α-galactosidase A in a patient diagnosed with or suspected of having Fabry disease. Certain methods comprise administering to a patient a therapeutically effective dose of a pharmacological chaperone for α-galactosidase A, wherein the patient has a splice site mutation in intron 4 of the nucleic acid sequence encoding α-galactosidase A. Also described are uses of pharmacological chaperones for the treatment of Fabry disease and compositions for use in the treatment of Fabry disease.

CROSS-REFERENCE TO RELATED APPLICATIONS

This a continuation of U.S. application Ser. No. 15/459,149, filed Mar.15, 2017, which claims the benefit under 35 U.S.C. § 119(e) to U.S.Provisional Application No. 62/311,511, filed Mar. 22, 2016, the entirecontents of which are incorporated herein by reference in theirentirety.

TECHNICAL FIELD

Principles and embodiments of the present invention relate generally tothe use of pharmacological chaperones for the treatment of Fabrydisease, particularly in patients with splice site mutations in intron 4of the GLA gene.

BACKGROUND

Many human diseases result from mutations that cause changes in theamino acid sequence of a protein which reduce its stability and mayprevent it from folding properly. Proteins generally fold in a specificregion of the cell known as the endoplasmic reticulum, or ER. The cellhas quality control mechanisms that ensure that proteins are folded intotheir correct three-dimensional shape before they can move from the ERto the appropriate destination in the cell, a process generally referredto as protein trafficking. Misfolded proteins are often eliminated bythe quality control mechanisms after initially being retained in the ER.In certain instances, misfolded proteins can accumulate in the ER beforebeing eliminated. The retention of misfolded proteins in the ERinterrupts their proper trafficking, and the resulting reducedbiological activity can lead to impaired cellular function andultimately to disease. In addition, the accumulation of misfoldedproteins in the ER may lead to various types of stress on cells, whichmay also contribute to cellular dysfunction and disease.

The majority of genetic mutations that lead to the production of lessstable or misfolded proteins are called missense mutations. Thesemutations result in the substitution of a single amino acid for anotherin the protein. However, in addition to missense mutations, there arealso other types of mutations that can result in proteins with reducedbiological activity. Another type of mutation that can cause disease isa splice site mutation. Splice site mutations are mutations in whichnucleotides are inserted, deleted or changed in number in the site wheresplicing of an intron takes place. This mutation can lead to incorrectprocessing of mRNA precursors, including exon skipping or splicing atcryptic splice points, resulting in gross structural and functionalalterations.

Such mutations can lead to lysosomal storage diseases (LSDs), which arecharacterized by deficiencies of lysosomal enzymes due to mutations inthe genes encoding the lysosomal enzymes. This results in the pathologicaccumulation of substrates of those enzymes, which include lipids,carbohydrates, and polysaccharides. Although there are many differentmutant genotypes associated with each LSD, many of the mutations aremissense mutations which can lead to the production of a less stableenzyme. These less stable enzymes are sometimes prematurely degraded bythe ER-associated degradation pathway. This results in the enzymedeficiency in the lysosome, and the pathologic accumulation ofsubstrate. Such mutant enzymes are sometimes referred to in thepertinent art as “folding mutants” or “conformational mutants.”

Fabry Disease is an LSD caused by a mutation to the GLA gene, whichencodes the enzyme α-galactosidase A (α-Gal A). The mutation causes thesubstrate globotriaosylceramide (Gb3, GL-3, or ceramide trihexoside) toaccumulate in various tissues and organs. Males with Fabry disease arehemizygotes because the disease genes are encoded on the X chromosome.Fabry disease is estimated to affect 1 in 40,000 and 60,000 males, andoccurs less frequently in females. There have been several approaches totreatment of Fabry disease.

One approved therapy for treating Fabry disease is enzyme replacementtherapy (ERT), which typically involves intravenous, infusion of apurified form of the corresponding wild-type protein (Fabrazyme®,Genzyme Corp.). One of the main complications with enzyme replacementtherapy is attainment and maintenance of therapeutically effectiveamounts of protein in vivo due to rapid degradation of the infusedprotein. The current approach to overcome this problem is to performnumerous costly high dose infusions. ERT has several additional caveats,such as difficulties with large-scale generation, purification, andstorage of properly folded protein; obtaining glycosylated nativeprotein; generation of an anti-protein immune response; and inability ofprotein to cross the blood-brain barrier to mitigate central nervoussystem pathologies (i.e., low bioavailability). In addition, replacementenzyme cannot penetrate the heart or kidney in sufficient amounts toreduce substrate accumulation in the renal podocytes or cardiacmyocytes, which figure prominently in Fabry pathology.

Gene therapy using recombinant vectors containing nucleic acid sequencesthat encode a functional protein, or using genetically modified humancells that express a functional protein, is also being developed totreat protein deficiencies and other disorders that benefit from proteinreplacement.

A third approach to treating some enzyme deficiencies involves the useof small molecule inhibitors to reduce production of the naturalsubstrate of deficient enzyme proteins, thereby ameliorating thepathology. This “substrate reduction” approach has been specificallydescribed for a class of about 40 related enzyme disorders calledlysosomal storage disorders that include glycosphingolipid storagedisorders. The small molecule inhibitors proposed for use as therapy arespecific for inhibiting the enzymes involved in synthesis ofglycolipids, reducing the amount of cellular glycolipid that needs to bebroken down by the deficient enzyme.

Another approach to treating Fabry disease has been treatment with whatare called specific pharmacological chaperones (SPCs). Such SPCs includesmall molecule inhibitors of α-Gal A, which can bind to the α-Gal A toincrease the stability of both mutant enzyme and the corresponding wildtype. However, successful candidates for SPC therapy should have amutation which results in the production of an enzyme that has thepotential to be stabilized and folded into a conformation that permitstrafficking out of the ER. Mutations which severely truncate the enzyme,such as nonsense mutations, or mutations in the catalytic domain whichprevent binding of the chaperone, will not be as likely to be“rescuable” or “enhanceable” using SPC therapy, i.e., to respond to SPCtherapy. While missense mutations outside the catalytic site are morelikely to be rescuable using SPCs, there is no guarantee, necessitatingscreening for responsive mutations.

Thus, even when Fabry disease is diagnosed by detecting deficient α-GalA activity in plasma or peripheral leukocytes (WBCs), it is verydifficult, if not impossible, to predict whether a particular Fabrypatient will respond to treatment with an SPC. Moreover, since WBCs onlysurvive for a short period of time in culture (in vitro), screening forSPC enhancement of α-Gal A is difficult and not optimal for the patient.

While some methods for evaluating screening patients for responsivenessto SPC therapy have been developed, these may not be applicable to allGLA mutations that cause Fabry disease. This means that there are Fabrypatients who are not receiving SPC treatment because they have not beenidentified as treatable, although they may in fact be good candidates.Thus, there remains a need to identify new GLA mutations that will beresponsive to SPC and make available new methods of treatment to Fabrypatients with these mutations.

SUMMARY

One aspect of the invention pertains to a method of treating a patientdiagnosed with Fabry disease. The method comprises administering to thepatient a therapeutically effective dose of a pharmacological chaperonefor α-galactosidase A, wherein the patient has a splice site mutation inintron 4 of the nucleic acid sequence encoding α-galactosidase A. In oneor more embodiments, the mutation is G9331A relative to SEQ ID NO: 1. Insome embodiments, the pharmacological chaperone comprises1-deoxygalactonojirimycin or salt thereof. In one or more embodiments,the dose of 1-deoxygalactonojirimycin or salt thereof is from about 25mg to about 250 mg. In some embodiments, the salt of1-deoxygalactonojirimycin is 1-deoxygalactonojirimycin hydrochloride. Inone or more embodiments, the dose is about 150 mg every other day of1-deoxygalactonojirimycin hydrochloride or an equivalent dose of1-deoxygalactonojirimycin or a salt thereof other than the hydrochloridesalt. In some embodiments, the 1-deoxygalactonojirimycin or salt thereofis administered orally or by injection. These embodiments may becombined with one another or with other embodiments of the invention,for example embodiments relating to a method of enhancingα-galactosidase A in a patient diagnosed with or suspected of havingFabry disease, use of a pharmacological chaperone for α-galactosidase Afor the manufacture of a medicament for treating a patient diagnosedwith Fabry disease or to a pharmacological chaperone for α-galactosidaseA for use in treating a patient diagnosed with Fabry disease as well asembodiments relating to amenable mutations, suitable SPCs and dosages,formulations and routs of administration thereof.

Another aspect of the invention pertains to a method of enhancingα-galactosidase A in a patient diagnosed with or suspected of havingFabry disease. The method comprises administering to a patient atherapeutically effective dose of a pharmacological chaperone forα-galactosidase A, wherein the patient has a splice site mutation inintron 4 of the nucleic acid sequence encoding α-galactosidase A. In oneor more embodiments, the mutation is G9331A relative to SEQ ID NO: 1. Insome embodiments, the pharmacological chaperone comprises1-deoxygalactonojirimycin or salt thereof. In one or more embodiments,the dose of 1-deoxygalactonojirimycin or salt thereof is from about 25mg to about 250 mg. In some embodiments, the salt of1-deoxygalactonojirimycin is 1-deoxygalactonojirimycin hydrochloride. Inone or more embodiments, the dose is about 150 mg every other day of1-deoxygalactonojirimycin hydrochloride or an equivalent dose of1-deoxygalactonojirimycin or a salt thereof other than the hydrochloridesalt. In some embodiments, the 1-deoxygalactonojirimycin or salt thereofis administered orally or by injection. These embodiments may becombined with one another or with other embodiments of the invention,for example embodiments relating to a method of treating a patient withFabry disease, use of a pharmacological chaperone for α-galactosidase Afor the manufacture of a medicament for treating a patient diagnosedwith Fabry disease or to a pharmacological chaperone for α-galactosidaseA for use in treating a patient diagnosed with Fabry disease as well asembodiments relating to amenable mutations, suitable SPCs and dosages,formulations and routs of administration thereof.

Another aspect of the invention pertains to use of a pharmacologicalchaperone for α-galactosidase A for the manufacture of a medicament fortreating a patient diagnosed with Fabry disease, wherein the patient hasa splice site mutation in intron 4 of the nucleic acid sequence encodingα-galactosidase A. In one or more embodiments, the mutation is G9331Arelative to SEQ ID NO: 1. In some embodiments, the pharmacologicalchaperone comprises 1-deoxygalactonojirimycin or salt thereof. In one ormore embodiments, the dose of 1-deoxygalactonojirimycin or salt thereofis from about 25 mg to about 250 mg. In some embodiments, the salt of1-deoxygalactonojirimycin is 1-deoxygalactonojirimycin hydrochloride. Inone or more embodiments, the dose is about 150 mg every other day of1-deoxygalactonojirimycin hydrochloride or an equivalent dose of1-deoxygalactonojirimycin or a salt thereof other than the hydrochloridesalt. In some embodiments, the 1-deoxygalactonojirimycin or salt thereofis administered orally or by injection. These embodiments may becombined with one another or with other embodiments of the invention,for example embodiments relating to a method of treating a patient withFabry disease, a method of enhancing α-galactosidase A in a patientdiagnosed with or suspected of having Fabry disease, or to apharmacological chaperone for α-galactosidase A for use in treating apatient diagnosed with Fabry disease as well as embodiments relating toamenable mutations, suitable SPCs and dosages, formulations and routs ofadministration thereof.

Another aspect of the invention pertains to a pharmacological chaperonefor α-galactosidase A for use in treating a patient diagnosed with Fabrydisease, wherein the patient has a splice site mutation in intron 4 ofthe nucleic acid sequence encoding α-galactosidase A. In one or moreembodiments, the mutation is G9331A relative to SEQ ID NO: 1. In someembodiments, the pharmacological chaperone comprises1-deoxygalactonojirimycin or salt thereof. In one or more embodiments,the dose of 1-deoxygalactonojirimycin or salt thereof is from about 25mg to about 250 mg. In some embodiments, the salt of1-deoxygalactonojirimycin is 1-deoxygalactonojirimycin hydrochloride. Inone or more embodiments, the dose is about 150 mg every other day of1-deoxygalactonojirimycin hydrochloride or an equivalent dose of1-deoxygalactonojirimycin or a salt thereof other than the hydrochloridesalt. In some embodiments, the 1-deoxygalactonojirimycin or salt thereofis administered orally or by injection. These embodiments may becombined with one another or with other embodiments of the invention,for example embodiments relating to a method of treating a patient withFabry disease, a method of enhancing α-galactosidase A in a patientdiagnosed with or suspected of having Fabry disease or use of apharmacological chaperone for α-galactosidase A for the manufacture of amedicament for treating a patient diagnosed with Fabry disease as wellas embodiments relating to amenable mutations, suitable SPCs anddosages, formulations and routs of administration thereof.

Another aspect of the invention pertains to a pharmaceutical compositionfor use in the treatment of Fabry disease comprising a pharmacologicalchaperone for α-galactosidase A, wherein the patient has a splice sitemutation in intron 4 of the nucleic acid sequence encoding-galactosidase A.

Various embodiments are listed below. It will be understood that theembodiments listed below may be combined not only as listed below, butin other suitable combinations in accordance with the scope of theinvention.

BRIEF DESCRIPTION OF THE DRAWINGS

FIGS. 1A-E shows the full DNA sequence of human wild type GLA gene (SEQID NO: 1);

FIG. 2 shows the wild type GLA protein (SEQ ID NO: 2);

FIG. 3 shows a partial sequence of the GLA gene showing splice sitemutation G9331A (SEQ ID NO: 3);

FIG. 4 shows the α-Gal A activity in mutant lymphoblasts exposed to DGJ;

FIG. 5 shows the α-Gal A activity in control lymphoblasts exposed toDGJ;

FIG. 6 is a Western blot showing α-Gal A activity in mutant lymphoblastswith and without incubation with DGJ;

FIG. 7 is an electrophoresis gel showing the presence of an SRY gene;

FIG. 8 is an electrophoresis gel showing the presence or absence of aBfa I restriction site; and

FIG. 9 shows the sequencing of three amplified PCR fragments fromlymphoblast genomic DNA.

DETAILED DESCRIPTION

Before describing several exemplary embodiments of the invention, it isto be understood that the invention is not limited to the details ofconstruction or process steps set forth in the following description.The invention is capable of other embodiments and of being practiced orbeing carried out in various ways.

Various aspects of the invention pertain to identification of new GLAmutations in Fabry patients who will respond to treatment withpharmacological chaperones. Other aspects of the invention pertain tothe treatment of these Fabry patients, as well. For example, it has beensurprisingly discovered that the low α-Gal A activity resulting from thesplice site mutation G9331A in the GLA gene can be increased whenexposed to pharmacological chaperones. By extension, patients with thesetypes of mutations will be responsive to treatment with pharmacologicalchaperones, where it was previously thought that patients with a splicesite mutation in the GLA gene would not be responsive to treatmentbecause splice site mutations generally cause such major changes in theenzyme.

Definitions

The terms used in this specification generally have their ordinarymeanings in the art, within the context of this invention and in thespecific context where each term is used. Certain terms are discussedbelow, or elsewhere in the specification, to provide additional guidanceto the practitioner in describing the compositions and methods of theinvention and how to make and use them.

The term “Fabry disease” refers to an X-linked inborn error ofglycosphingolipid catabolism due to deficient lysosomal α-galactosidaseA activity. This defect causes accumulation of globotriaosylceramide(ceramide trihexoside) and related glycosphingolipids in vascularendothelial lysosomes of the heart, kidneys, skin, and other tissues.

The term “atypical Fabry disease” refers to patients with primarilycardiac manifestations of the α-Gal A deficiency, namely progressiveglobotriaosylceramide (GL-3) accumulation in myocardial cells that leadsto significant enlargement of the heart, particularly the leftventricle.

A “carrier” is a female who has one X chromosome with a defective α-GalA gene and one X chromosome with the normal gene and in whom Xchromosome inactivation of the normal allele is present in one or morecell types. A carrier is often diagnosed with Fabry disease.

A “patient” refers to a subject who has been diagnosed with or issuspected of having a particular disease. The patient may be human oranimal.

A “Fabry disease patient” refers to an individual who has been diagnosedwith or suspected of having Fabry disease and has a mutated α-Gal A asdefined further below. Characteristic markers of Fabry disease can occurin male hemizygotes and female carriers with the same prevalence,although females typically are less severely affected.

Human α-galactosidase A (α-Gal A) refers to an enzyme encoded by thehuman GLA gene. The full DNA sequence of α-Gal A, including introns andexons, is available in GenBank Accession No. X14448.1 and shown in FIGS.1A-E (SEQ ID NO: 1). The human α-Gal A enzyme consists of 429 aminoacids and is available in GenBank Accession Nos. X14448.1 and U78027 andshown in FIG. 2 (SEQ ID NO: 2).

The term “mutant protein” includes a protein which has a mutation in thegene encoding the protein which results in the inability of the proteinto achieve a stable conformation under the conditions normally presentin the ER. The failure to achieve a stable conformation results in asubstantial amount of the enzyme being degraded, rather than beingtransported to the lysosome. Such a mutation is sometimes called a“conformational mutant.” Such mutations include, but are not limited to,missense mutations, and in-frame small deletions and insertions.

As used herein in one embodiment, the term “mutant α-Gal A” includes anα-Gal A which has a mutation in the gene encoding α-Gal A which resultsin the inability of the enzyme to achieve a stable conformation underthe conditions normally present in the ER. The failure to achieve astable conformation results in a substantial amount of the enzyme beingdegraded, rather than being transported to the lysosome.

As used herein, the term “specific pharmacological chaperone” (“SPC”) or“pharmacological chaperone” refers to any molecule including a smallmolecule, protein, peptide, nucleic acid, carbohydrate, etc. thatspecifically binds to a protein and has one or more of the followingeffects: (i) enhances the formation of a stable molecular conformationof the protein; (ii) induces trafficking of the protein from the ER toanother cellular location, preferably a native cellular location, i.e.,prevents ER-associated degradation of the protein; (iii) preventsaggregation of misfolded proteins; and/or (iv) restores or enhances atleast partial wild-type function and/or activity to the protein. Acompound that specifically binds to e.g., α-Gal A, means that it bindsto and exerts a chaperone effect on the enzyme and not a generic groupof related or unrelated enzymes. More specifically, this term does notrefer to endogenous chaperones, such as BiP, or to non-specific agentswhich have demonstrated non-specific chaperone activity against variousproteins, such as glycerol, DMSO or deuterated water, i.e., chemicalchaperones. In the present invention, the SPC may be a reversiblecompetitive inhibitor.

A “competitive inhibitor” of an enzyme can refer to a compound whichstructurally resembles the chemical structure and molecular geometry ofthe enzyme substrate to bind the enzyme in approximately the samelocation as the substrate. Thus, the inhibitor competes for the sameactive site as the substrate molecule, thus increasing the Km.Competitive inhibition is usually reversible if sufficient substratemolecules are available to displace the inhibitor, i.e., competitiveinhibitors can bind reversibly. Therefore, the amount of enzymeinhibition depends upon the inhibitor concentration, substrateconcentration, and the relative affinities of the inhibitor andsubstrate for the active site.

As used herein, the term “specifically binds” refers to the interactionof a pharmacological chaperone with a protein such as α-Gal A,specifically, an interaction with amino acid residues of the proteinthat directly participate in contacting the pharmacological chaperone. Apharmacological chaperone specifically binds a target protein, e.g.,α-Gal A, to exert a chaperone effect on the protein and not a genericgroup of related or unrelated proteins. The amino acid residues of aprotein that interact with any given pharmacological chaperone may ormay not be within the protein's “active site.” Specific binding can beevaluated through routine binding assays or through structural studies,e.g., co-crystallization, NMR, and the like. The active site for α-Gal Ais the substrate binding site.

“Deficient α-Gal A activity” refers to α-Gal A activity in cells from apatient which is below the normal range as compared (using the samemethods) to the activity in normal individuals not having or suspectedof having Fabry or any other disease (especially a blood disease).

As used herein, the terms “enhance α-Gal A activity” or “increase α-GalA activity” refer to increasing the amount of α-Gal A that adopts astable conformation in a cell contacted with a pharmacological chaperonespecific for the α-Gal A, relative to the amount in a cell (preferablyof the same cell-type or the same cell, e.g., at an earlier time) notcontacted with the pharmacological chaperone specific for the α-Gal A.This term also refers to increasing the trafficking of α-Gal A to thelysosome in a cell contacted with a pharmacological chaperone specificfor the α-Gal A, relative to the trafficking of α-Gal A not contactedwith the pharmacological chaperone specific for the protein. These termsrefer to both wild-type and mutant α-Gal A. In one embodiment, theincrease in the amount of α-Gal A in the cell is measured by measuringthe hydrolysis of an artificial substrate in lysates from cells thathave been treated with the SPC. An increase in hydrolysis is indicativeof increased α-Gal A activity.

The term “α-Gal A activity” refers to the normal physiological functionof a wild -type α-Gal A in a cell. For example, α-Gal A activityincludes hydrolysis of GL-3.

A “responder” is an individual diagnosed with or suspected of having alysosomal storage disorder, such, for example Fabry disease, whose cellsexhibit sufficiently increased α-Gal A activity, respectively, and/oramelioration of symptoms or improvement in surrogate markers, inresponse to contact with an SPC. Non-limiting examples of improvementsin surrogate markers for Fabry are lyso-GB3 and those disclosed in USPatent Application Publication No. US 2010-0113517.

Non-limiting examples of improvements in surrogate markers for Fabrydisease disclosed in US 2010/0113517 include increases in α-Gal A levelsor activity in cells (e.g., fibroblasts) and tissue; reductions in ofGL-3 accumulation; decreased plasma concentrations of homocysteine andvascular cell adhesion molecule-1 (VCAM-1); decreased GL-3 accumulationwithin myocardial cells and valvular fibrocytes; reduction in cardiachypertrophy (especially of the left ventricle), amelioration of valvularinsufficiency, and arrhythmias; amelioration of proteinuria; decreasedurinary concentrations of lipids such as CTH, lactosylceramide,ceramide, and increased urinary concentrations of glucosylceramide andsphingomyelin; the absence of laminated inclusion bodies (Zebra bodies)in glomerular epithelial cells; improvements in renal function;mitigation of hypohidrosis; the absence of angiokeratomas; andimprovements hearing abnormalities such as high frequency sensorineuralhearing loss progressive hearing loss, sudden deafness, or tinnitus.Improvements in neurological symptoms include prevention of transientischemic attack (TIA) or stroke; and amelioration of neuropathic painmanifesting itself as acroparaesthesia (burning or tingling inextremities). Another type of clinical marker that can be assessed forFabry disease is the prevalence of deleterious cardiovascularmanifestations. Common cardiac-related signs and symptoms of Fabrydisease include Left ventricular hypertrophy, valvular disease(especially mitral valve prolapse and/or regurgitation), prematurecoronary artery disease, angina, myocardial infarction, conductionabnormalities, arrhythmias, congestive heart failure.

The dose that achieves one or more of the aforementioned responses is a“therapeutically effective dose.”

The phrase “pharmaceutically acceptable” refers to molecular entitiesand compositions that are physiologically tolerable and do not typicallyproduce untoward reactions when administered to a human. In someembodiments, as used herein, the term “pharmaceutically acceptable”means approved by a regulatory agency of the Federal or a stategovernment or listed in the U.S. Pharmacopoeia or other generallyrecognized pharmacopoeia for use in animals, and more particularly inhumans. The term “carrier” in reference to a pharmaceutical carrierrefers to a diluent, adjuvant, excipient, or vehicle with which thecompound is administered. Such pharmaceutical carriers can be sterileliquids, such as water and oils. Water or aqueous solution salinesolutions and aqueous dextrose and glycerol solutions are preferablyemployed as carriers, particularly for injectable solutions. Suitablepharmaceutical carriers are described in “Remington's PharmaceuticalSciences” by E. W. Martin, 18th Edition, or other editions.

As used herein, the term “isolated” means that the referenced materialis removed from the environment in which it is normally found. Thus, anisolated biological material can be free of cellular components, i.e.,components of the cells in which the material is found or produced. Inthe case of nucleic acid molecules, an isolated nucleic acid includes aPCR product, an mRNA band on a gel, a cDNA, or a restriction fragment.In another embodiment, an isolated nucleic acid is preferably excisedfrom the chromosome in which it may be found, and more preferably is nolonger joined to non-regulatory, non-coding regions, or to other genes,located upstream or downstream of the gene contained by the isolatednucleic acid molecule when found in the chromosome. In yet anotherembodiment, the isolated nucleic acid lacks one or more introns.Isolated nucleic acids include sequences inserted into plasmids,cosmids, artificial chromosomes, and the like. Thus, in a specificembodiment, a recombinant nucleic acid is an isolated nucleic acid. Anisolated protein may be associated with other proteins or nucleic acids,or both, with which it associates in the cell, or with cellularmembranes if it is a membrane -associated protein. An isolatedorganelle, cell, or tissue is removed from the anatomical site in whichit is found in an organism. An isolated material may be, but need notbe, purified.

The terms “about” and “approximately” shall generally mean an acceptabledegree of error for the quantity measured given the nature or precisionof the measurements. Typical, exemplary degrees of error are within 20percent (%), preferably within 10%, and more preferably within 5% of agiven value or range of values. Alternatively, and particularly inbiological systems, the terms “about” and “approximately” may meanvalues that are within an order of magnitude, preferably within 10- or5-fold, and more preferably within 2-fold of a given value. Numericalquantities given herein are approximate unless stated otherwise, meaningthat the term “about” or “approximately” can be inferred when notexpressly stated.

The term “enzyme replacement therapy” or “ERT” refers to theintroduction of a non-native, purified enzyme into an individual havinga deficiency in such enzyme. The administered protein can be obtainedfrom natural sources or by recombinant expression (as described ingreater detail below). The term also refers to the introduction of apurified enzyme in an individual otherwise requiring or benefiting fromadministration of a purified enzyme, e.g., suffering from enzymeinsufficiency. The introduced enzyme may be a purified, recombinantenzyme produced in vitro, or protein purified from isolated tissue orfluid, such as, e.g., placenta or animal milk, or from plants.

Pharmacological Chaperones

The binding of small molecule inhibitors of enzymes associated with LSDscan increase the stability of both mutant enzyme and the correspondingwild-type enzyme (see U.S. Pat. Nos. 6,274,597; 6,583,158; 6,589,964;6,599,919; 6,916,829, and 7,141,582 all incorporated herein byreference). In particular, administration of small molecule derivativesof glucose and galactose, which are specific, selective competitiveinhibitors for several target lysosomal enzymes, effectively increasedthe stability of the enzymes in cells in vitro and, thus, increasedtrafficking of the enzymes to the lysosome. Thus, by increasing theamount of enzyme in the lysosome, hydrolysis of the enzyme substrates isexpected to increase. The original theory behind this strategy was asfollows: since the mutant enzyme protein is unstable in the ER (Ishii etal., Biochem. Biophys. Res. Comm. 1996; 220: 812-815), the enzymeprotein is retarded in the normal transport pathway (ER→Golgiapparatus→endosomes→lysosome) and prematurely degraded. Therefore, acompound which binds to and increases the stability of a mutant enzyme,may serve as a “chaperone” for the enzyme and increase the amount thatcan exit the ER and move to the lysosomes. In addition, because thefolding and trafficking of some wild-type proteins is incomplete, withup to 70% of some wild-type proteins being degraded in some instancesprior to reaching their final cellular location, the chaperones can beused to stabilize wild-type enzymes and increase the amount of enzymewhich can exit the ER and be trafficked to lysosomes. This strategy hasbeen shown to increase several lysosomal enzymes in vitro and in vivo,including β-glucocerebrosidase and α-glucosidase, deficiencies of whichare associated with Gaucher and Pompe disease, respectively.

In one or more embodiments, the SPC is 1-deoxygalactonojirimycin (DGJ)which refers to a compound having the following structures:

or a pharmaceutically acceptable salt, ester or prodrug of1-deoxygalactonojirimycin. The hydrochloride salt of DGJ is known asmigalastat hydrochloride (Migalastat).

Still other SPCs for α-Gal A are described in U.S. Pat. Nos. 6,274,597,6,774,135, and 6,599,919, and include a-3,4-di-epi-homonojirimycin,4-epi-fagomine, α-allo -homonojirimycin,N-methyl-deoxygalactonojirimycin, β-1-C-butyl-deoxygalactonojirimycin,α-galacto-homonojirimycin, calystegine A₃, calystegine B₂, calystegineB₃, N-methyl-calystegine A₃, N-methyl-calystegine B₂ andN-methyl-calystegine B₃.

In a specific embodiment, the SPC comprises 1-deoxygalactonojirimycin orsalt thereof. In further embodiments, the SPC comprises1-deoxygalactonojirimycin hydrochloride.

Any of these SPCs for α-Gal A may be used in combination with any of theother embodiments of the invention, for example embodiments relating toa method of treating a patient with Fabry disease, a method of enhancingα-galactosidase A in a patient diagnosed with or suspected of havingFabry disease, use of a pharmacological chaperone for α-galactosidase Afor the manufacture of a medicament for treating a patient diagnosedwith Fabry disease or to a pharmacological chaperone for α-galactosidaseA for use in treating a patient diagnosed with Fabry disease as well asembodiments relating to suitable doses of SPCs, amenable mutations andto the treatment of a Fabry patient having a splice site mutation inintron 4 of the nucleic acid sequence encoding α-galactosidase A.

Identification of GLA Mutations Responsive to Pharmacological Chaperones

Because Fabry disease is rare, involves multiple organs, has a wide agerange of onset, and is heterogeneous, proper diagnosis is a challenge.Awareness is low among health care professionals and misdiagnoses arefrequent. Diagnosis of Fabry disease is most often confirmed on thebasis of decreased α-Gal A activity in plasma or peripheral leukocytes(WBCs) once a patient is symptomatic, coupled with mutational analysis.In females, diagnosis is even more challenging since the enzymaticidentification of carrier females is less reliable due to random X-chromosomal inactivation in some cells of carriers. For example, someobligate carriers (daughters of classically affected males) have α-Gal Aenzyme activities ranging from normal to very low activities. Sincecarriers can have normal α-Gal A enzyme activity in leukocytes, only theidentification of an α-Gal A mutation by genetic testing providesprecise carrier identification and/or diagnosis.

An “amenable mutation” as used herein means that the α-Gal A activity ofa cell having the mutation will increase when incubated with apharmacological chaperone of α-Gal A. In some embodiments, the followingcriteria will be met: ≥about 1.2-fold relative increase in α-Gal Aactivity and/or ≥about a 3.0% of wild-type (WT) absolute increase after10 μM pharmacological chaperone incubation. In some embodiments, thepharmacological chaperone is migalastat. Any of the embodiments relatingto amenable mutations can be combined with any of the other embodimentsof the invention, for example embodiments relating to a method oftreating a patient with Fabry disease, a method of enhancingα-galactosidase A in a patient diagnosed with or suspected of havingFabry disease, use of a pharmacological chaperone for α-galactosidase Afor the manufacture of a medicament for treating a patient diagnosedwith Fabry disease or to a pharmacological chaperone for α-galactosidaseA for use in treating a patient diagnosed with Fabry disease as well asembodiments relating to the SPCs, suitable dosages thereof, and to thetreatment of a Fabry patient having a splice site mutation in intron 4of the nucleic acid sequence encoding α-galactosidase A.

Previous screening methods have been provided that assess enzymeenhancement prior to the initiation of treatment. For example, an assayusing HEK-293 cells has been utilized in clinical trials to predictwhether a given mutation will be responsive to pharmacological chaperone(e.g., migalastat) treatment. In this assay, cDNA constructs arecreated. The corresponding α-Gal A mutant forms are transientlyexpressed in HEK-293 cells. Cells are then incubated±migalastat (17 nMto 1 mM) for 4 to 5 days. After, α-Gal A levels are measured in celllysates using a synthetic fluorogenic substrate (4-MU-α-Gal) or bywestern blot. This has been done for known disease-causing missense orsmall in-frame insertion/deletion mutations. Mutations that havepreviously been identified as responsive to an SPC (e.g. DGJ) usingthese methods are listed in U.S. Pat. No. 8,592,362. However, thisHEK-293 assay uses recombinant GLA cDNA; thus, the mutant α-Gal A isexpressed independent of pre-mRNA splicing, and the HEK-293 assay cannotbe used to predict response of splice site mutations.

Nevertheless, as described herein, lymphoblast assays may instead beused to identify mutations that meet the above-mentioned amenabilitycriteria. For the splice site mutations described herein, lymphoblastcultures can be derived from male patients with the mutation, followedby the assay. Lymphoblasts may be derived by culturing in a suspensionin a medium (e.g., supplemented with fetal calf serum andpenicillin-streptomycin at 37° C., 5% CO2). Fabry patient lymphoblastlines can then be immortalized and established byphytohaemagglutininstimulated Epstein-Barr virus transformation ofperipheral blood mononuclear cells using blood samples. The lymphoblastscan then be seeded and incubated with varying concentrations ofchaperone, and evaluated using methods known in the art (See e.g.,Benjamin E. R., et al. Inherited Metab. Dis. 2009; 32:424-440).

Accordingly, another aspect of the invention pertains to a method fordetermining whether a Fabry disease patient will respond to treatmentwith a pharmacological chaperone for α-galactosidase A, wherein thepatient does not have a missense mutation in an exon of the of thenucleic acid sequence encoding α-galactosidase A (SEQ ID NO: 1), themethod comprising isolating genomic DNA encoding α-galactosidase A froma sample of lymphoblasts from the patient, optionally amplifying the DNAor a fragment thereof comprising intron 4 and determining the presenceor absence of a splice site mutation in intron 4, wherein a patienthaving a splice site mutation in intron 4 is responsive to treatmentwith a pharmacological chaperone for α-galactosidase A.

Splice Site Mutations in Intron 4 and the Treatment of Fabry Disease

Accordingly, one or more embodiments pertains to the treatment of aFabry patient having a splice site mutation in intron 4 of the nucleicacid sequence encoding α-galactosidase A. Because splice site mutationsoccur in the introns, mutations are described relative to the full GLADNA sequence, shown in FIGS. 1A-E (SEQ ID NO: 1). Intron 4 spans nucleicacid positions 8413 through 10130 relative to SEQ ID NO: 1. One suchmutation is the G9331A mutation (also known as IVS4+919G→A). An excerptof the GLA DNA sequence showing this mutation is shown in FIG. 3 and SEQID NO: 3. This mutation is associated with the cardiac variant form ofFabry disease. Specifically, patients with this form of the disease mayexperience left-ventricular hypertrophy and have cardiomyopathy. Thismutation also has shown a high prevalence among newborns (˜-1 in 1600males) and patients with idiopathic hypertrophic cardiomyopathy in theTaiwan Chinese population (Lin, H., et al. Cardiovascular Genetics.2009; 2:450-456). Indeed, the mutation was found in 82% of newborns whoscreened positive for Fabry disease in the Taiwan Chinese population(Id.). In the GLA gene, G9331A occurs in the middle of intron 4 (Ishii,et al. Am. J. Hum. Genet. 70:994-1002, 2002). This mutation results inthe increased recognition of a normally weak splice site, resulting inthe insertion of an additional 57-nucleotide sequence into the α-Gal Atranscript. The inserted sequence introduces a premature terminationcodon downstream from exon 4, with a predicted truncated protein productof 222 amino acid residues. The abnormal α-Gal A mRNA comprised morethan 70% of the total α-Gal A mRNA in lymphoblasts derived from a maleFabry patient with this mutation. However, some wild-type α-Gal A mRNAwas expressed and the resultant residual α-Gal A activity was less than10% of normal (Ishii, Nakao et al. 2002).

As shown in the examples below, the G9331A mutation was assessed forresponse to DGJ in a male Fabry patient derived lymphoblast assay. Themale Fabry patient lymphoblast assay correlates with the HEK assay (Wuet al. Human Mutation 2011, FIG. 5), and this mutation meets theamenability criteria based on the lymphoblast assay. Because themutation meets the aforementioned amenability criteria in thelymphoblast assay, it is thought that the mutation will show a responseto DGJ in vivo. Further, the age of onset, progression, and severity ofFabry disease is at least partly dependent on the rate of substrateaccumulation, which correlates to the enzymatic activity in lysosomes.Thus, a complete lack of residual activity can correspond to rapidsubstrate accumulation, and therefore a more severe form of the disease(having early onset and rapid progression). However, even smallquantities of residual activity may be enough to degrade a large amountsof substrate. This in turn would lead to milder disease with later onsetand slower progression because of the slowed. Considering these factors,it is thought that even modest increases in enzymatic activity canreduce the effect of a severe clinical phenotype. Data suggests that formost LSDs, just 1% to 6% of normal activity has been estimated assufficient to delay or prevent disease onset or yield a more mild formof the disease. That is, just small increases in activity could have asignificant impact on substrate levels, and hence disease severity andthe rate of disease progression. Conversely, it is expected that amutant lysosomal enzyme that shows no response in vitro would also notrespond in vivo.

Accordingly, one aspect of the invention pertains to use of SPCs for thetreatment of Fabry disease in a patient having a mutation in the geneencoding α-galactosidase A, wherein the patient is identified as havinga splice site mutation in intron 4 relative to a human α-galactosidase Aencoded by a nucleic acid sequence set forth in SEQ ID NO: 1. Anotheraspect of the invention pertains a method of treating a patientdiagnosed with Fabry disease. In one or more embodiments, the methodcomprises administering to a patient a therapeutically effective dose ofa pharmacological chaperone (SPC) of α-Gal A. In further embodiments,the patient has a splice site mutation in intron 4 of the nucleic acidsequence encoding α-galactosidase A. Another aspect of the inventionpertains to a method of enhancing α-galactosidase A in a patientdiagnosed with or suspected of having Fabry disease. In one or moreembodiments, the method comprises administering to a patient atherapeutically effective dose of a pharmacological chaperone (SPC) ofα-Gal A, wherein the patient has a mutant α-galactosidase A encoded by anucleic acid sequence having a splice site mutation relative to SEQ IDNO: 1. Details and further embodiments of these uses and methods followsbelow. Any of the embodiments relating a method of treating a patientwith Fabry disease, a method of enhancing α-galactosidase A in a patientdiagnosed with or suspected of having Fabry disease, use of apharmacological chaperone for α-galactosidase A for the manufacture of amedicament for treating a patient diagnosed with Fabry disease or to apharmacological chaperone for α-galactosidase A for use in treating apatient diagnosed with Fabry disease wherein the patient is identifiedas having a splice site mutation in intron 4 relative to a humanα-galactosidase A encoded by a nucleic acid sequence set forth in SEQ IDNO: 1 can be combined with any of the other embodiments of theinvention, for example embodiments relating to the SPCs and suitabledosages thereof.

In one or more embodiments, the patient may have other mutations intheir GLA gene. For example, there may be other mutations in the intronregion which may or may not affect the resulting α-Gal A enzyme. Thus,in one or more embodiments, the patient has mutant α-galactosidase Aencoded by a nucleic acid sequence having 95, 96, 97, 98, 99 or 99.5%identity to SEQ ID NO: 1. In some embodiments, the patient has amutation consisting essentially of G9331A relative to SEQ ID NO: 1.Again, any of these embodiments can be combined with any of the otherembodiments of the invention, for example embodiments relating toamenable mutations, the SPCs and suitable dosages thereof.

It is unexpected that pharmacological chaperones would be effective totreat Fabry disease due to such splice site mutations. As discussedabove, it is not even possible to test such mutations via the standardHEK-293 assay to determine responsiveness to incubation withpharmacological chaperone. Moreover, with respect to G9331A, it had beenpreviously thought that the G9331A mutation was unresponsive totreatment with DGJ (See Benjamin E. R., et al. Inherited Metab. Dis.2009; 32:424-440). Furthermore, the amenability of G9331A could not bepredicted from the mutations known to be responsive because splice sitemutations can lead to incorrect processing of mRNA precursors, includingexon skipping or splicing at cryptic splice points, resulting in grossstructural and functional alterations. While not wishing to be bound toany particular theory, it is thought that pharmacological chaperones areeffective by enhancing the activity of the small amounts of wild-typeenzyme produced. The synthesis, folding and trafficking of the wild-typeenzyme may not be completely efficient. The pharmacological chaperonemay stabilize the wild-type.

Treatment of a patient having the G9331 mutation or another splice sitemutation in intron 4 is expected to result in amelioration of one ormore of the symptoms described above. Treatment progress can beevaluated and monitored by tracking certain parameters. For example, asdiscussed above, one clinical marker that can be assessed for Fabrydisease is the prevalence of deleterious cardiovascular manifestations.Cardiac complications are common in Fabry disease and are the main causeof death. The most frequent cardiac manifestation is LVH, which is animportant risk factor for cardiac events. Reduction of LV-mass has beenshown to improve outcomes in these patients. Migalastat treatment for upto 24-months significantly reduced LVMi, with larger decreases seen inpatients with baseline LVH. The effect of ERT on LV-mass appears to beinconsistent. In a recent study, LVMi continued to increase in men >30years of age treated with ERT. Another ERT study found that the initialimprovement in LVMi diminished over time. As indicated by stable leftventricular posterior wall thickness and the decrease inintraventricular septal wall thickness, the reduction in LVMi inmigalastat-treated patients in our study was not due to fibrosis. Thisreduction in LVMi is expected to contribute to a decrease in the cardiaccomplications that are common in Fabry disease.

Progressive decline in renal function is also a major complication ofFabry disease. For example, patients associated with a classic Fabryphenotype, which is associated with progressive renal impairment thatcan lead to dialysis or renal transplantation. TheChronic-Kidney-Disease-Prognosis-Consortium, eGFRCKD-EPI decline hasbeen shown to be a reliable surrogate for subsequent risk ofend-stage-renal disease and mortality.

Another method for monitoring treatment is to follow lyso-GB₃(globotriaosylsphingosine) as a biomarker. Lyso-GB₃ is normallyincreased in patients with the disease, and can be detected in theurine. Thus, successful treatment of a patient will be marked by adecrease in the amount of lyso-GB₃.

Formulation and Administration

The dose and dosing regimen of pharmacological chaperone (e.g., DGJ)administration may vary depending on the patient since there is so muchheterogeneity among mutations, and depending on the patient's residualα-GAL activity. As non-limiting examples, the following doses andregimens are expected to be sufficient to increase α-GAL in most“rescuable” individuals: 25 mg twice a day (b.i.d); 50 mg once a day; 50mg b.i.d.; 50 mg once every other day, 75 mg once a day; 75 mg b.i.d.;100 mg once a day; 100 mg b.i.d.; 150 mg once a day; 150 mg b.i.d., 150mg once every other day; 250 mg once a day; 250 mg b.i.d. and 250 mgonce every other day. In specific embodiments, the doses are 50 mg oncea day; 50 mg once every other day; 150 mg once a day; 150 mg once everyother day. In one or more embodiments, these doses pertain to1-deoxygalactonojirimycin hydrochloride or an equivalent dose of1-deoxygalactonojirimycin or a salt thereof other than the hydrochloridesalt. In some embodiments, these doses pertain to the free base. Inalternate embodiments, these doses pertain to a salt of1-deoxygalactonojirimycin. In further embodiments, the salt of1-deoxygalactonojirimycin is 1-deoxygalactonojirimycin hydrochloride. Itis noted that 150 mg of 1-deoxygalactonojirimycin hydrochloride isequivalent to 123 mg of the free base form of 1-deoxygalactonojirimycin.Thus, in one or more embodiments the dose is 150 mg once every other dayof 1-deoxygalactonojirimycin hydrochloride or an equivalent dose of1-deoxygalactonojirimycin or a salt thereof other than the hydrochloridesalt. In further embodiments, the dose is 150 mg once every other day of1-deoxygalactonojirimycin hydrochloride. In other embodiments, the doseis 123 mg once every other day of the 1-deoxygalactonojirimycin freebase.

Administration of DGJ according to the present invention may be in aformulation suitable for any route of administration, but is preferablyadministered in an oral dosage form such as a tablet, capsule orsolution. As one example, the patient is orally administered capsuleseach containing 25 mg, 50 mg, 75 mg, 100 mg or 150 mg1-deoxygalactonojirimycin hydrochloride or an equivalent dose of1-deoxygalactonojirimycin or a salt thereof other than the hydrochloridesalt.

In particular embodiments, the dose of SPC (e.g.,1-deoxygalactonojirimycin or salt thereof) is from about 25 mg to about250 mg 1-deoxygalactonojirimycin hydrochloride or an equivalent dose of1-deoxygalactonojirimycin or a salt thereof other than the hydrochloridesalt. In further embodiments, the dose of SPC (e.g.,1-deoxygalactonojirimycin hydrochloride) is about 150 mg every otherday. In some embodiments, the SPC (e.g., 1-deoxygalactonojirimycin orsalt thereof) is administered orally. In one or more embodiments, theSPC (e.g., 1-deoxygalactonojirimycin or salt thereof) is administered byinjection. The SPC may be accompanied by a pharmaceutically acceptablecarrier, which may depend on the method of administration.

In one embodiment of the invention, the chaperone compound isadministered as monotherapy, and can be in a form suitable for any routeof administration, including e.g., orally in the form tablets orcapsules or liquid, in sterile aqueous solution for injection, or in adry lyophilized powder to be added to the formulation of the replacementenzyme during or immediately after reconstitution to prevent enzymeaggregation in vitro prior to administration.

When the chaperone compound is formulated for oral administration, thetablets or capsules can be prepared by conventional means withpharmaceutically acceptable excipients such as binding agents (e.g.jpregelatinized maize starch, polyvinylpyrrolidone or hydroxypropylmethylcellulose); fillers (e.g., lactose, microcrystalline cellulose orcalcium hydrogen phosphate); lubricants (e.g., magnesium stearate, talcor silica); disintegrants (e.g., potato starch or sodium starchglycolate); or wetting agents (e.g., sodium lauryl sulphate). Thetablets may be coated by methods well known in the art. Liquidpreparations for oral administration may take the form of, for example,solutions, syrups or suspensions, or they may be presented as a dryproduct for constitution with water or another suitable vehicle beforeuse. Such liquid preparations may be prepared by conventional means withpharmaceutically acceptable additives such as suspending agents (e.g.,sorbitol syrup, cellulose derivatives or hydrogenated edible fats);emulsifying agents (e.g., lecithin or acacia); non-aqueous vehicles(e.g., almond oil, oily esters, ethyl alcohol or fractionated vegetableoils); and preservatives (e.g., methyl or propyl-p -hydroxybenzoates orsorbic acid). The preparations may also contain buffer salts, flavoring,coloring and sweetening agents as appropriate. Preparations for oraladministration may be suitably formulated to give controlled release ofthe active chaperone compound.

The pharmaceutical formulations of the chaperone compound suitable forparenteral/injectable use generally include sterile aqueous solutions(where water soluble), or dispersions and sterile powders for theextemporaneous preparation of sterile injectable solutions ordispersion. In all cases, the form must be sterile and must be fluid tothe extent that easy syringability exists. It must be stable under theconditions of manufacture and storage and must be preserved against thecontaminating action of microorganisms such as bacteria and fungi. Thecarrier can be a solvent or dispersion medium containing, for example,water, ethanol, polyol (for example, glycerol, propylene glycol, andpolyethylene glycol, and the like), suitable mixtures thereof, andvegetable oils. The proper fluidity can be maintained, for example, bythe use of a coating such as lecithin, by the maintenance of therequired particle size in the case of dispersion and by the use ofsurfactants. Prevention of the action of microorganisms can be broughtabout by various antibacterial and antifungal agents, for example,parabens, chlorobutanol, phenol, benzyl alchohol, sorbic acid, and thelike. In many cases, it will be reasonable to include isotonic agents,for example, sugars or sodium chloride. Prolonged absorption of theinjectable compositions can be brought about by the use in thecompositions of agents delaying absorption, for example, aluminummonosterate and gelatin.

Sterile injectable solutions are prepared by incorporating the purifiedenzyme and the chaperone compound in the required amount in theappropriate solvent with various of the other ingredients enumeratedabove, as required, followed by filter or terminal sterilization.Generally, dispersions are prepared by incorporating the varioussterilized active ingredients into a sterile vehicle which contains thebasic dispersion medium and the required other ingredients from thoseenumerated above. In the case of sterile powders for the preparation ofsterile injectable solutions, the preferred methods of preparation arevacuum drying and the freeze -drying technique which yield a powder ofthe active ingredient plus any additional desired ingredient frompreviously sterile-filtered solution thereof.

The formulation can contain an excipient. Pharmaceutically acceptableexcipients which may be included in the formulation are buffers such ascitrate buffer, phosphate buffer, acetate buffer, and bicarbonatebuffer, amino acids, urea, alcohols, ascorbic acid, phospholipids;proteins, such as serum albumin, collagen, and gelatin; salts such asEDTA or EGTA, and sodium chloride; liposomes; polyvinylpyrollidone;sugars, such as dextran, mannitol, sorbitol, and glycerol; propyleneglycol and polyethylene glycol (e.g., PEG-4000, PEG-6000); glycerol;glycine or other amino acids; and lipids. Buffer systems for use withthe formulations include citrate; acetate; bicarbonate; and phosphatebuffers. Phosphate buffer is a preferred embodiment.

The route of administration of the chaperone compound may be oral(preferably) or parenteral, including intravenous, subcutaneous,intra-arterial, intraperitoneal, ophthalmic, intramuscular, buccal,rectal, vaginal, intraorbital, intracerebral, intradermal, intracranial,intraspinal, intraventricular, intrathecal, intracisternal,intracapsular, intrapulmonary, intranasal, transmucosal, transdermal, orvia inhalation.

Administration of the above-described parenteral formulations of thechaperone compound may be by periodic injections of a bolus of thepreparation, or may be administered by intravenous or intraperitonealadministration from a reservoir which is external (e.g., an i.v. bag) orinternal (e.g., a bioerodable implant).

Embodiments relating to pharmaceutical formulations and administrationmay be combined with any of the other embodiments of the invention, forexample embodiments relating to a method of treating a patient withFabry disease, a method of enhancing α-galactosidase A in a patientdiagnosed with or suspected of having Fabry disease, use of apharmacological chaperone for α-galactosidase A for the manufacture of amedicament for treating a patient diagnosed with Fabry disease or to apharmacological chaperone for α-galactosidase A for use in treating apatient diagnosed with Fabry disease as well as embodiments relating toamenable mutations, the SPCs and suitable dosages thereof.

In one or more embodiments, chaperone is administered in combinationwith enzyme replacement therapy. Enzyme replacement therapy increasesthe amount of protein by exogenously introducing wild-type orbiologically functional enzyme by way of infusion. This therapy has beendeveloped for many genetic disorders including lysosomal storagedisorders Fabry disease, as referenced above. After the infusion, theexogenous enzyme is expected to be taken up by tissues throughnon-specific or receptor-specific mechanism. In general, the uptakeefficiency is not high, and the circulation time of the exogenousprotein is short. In addition, the exogenous protein is unstable andsubject to rapid intracellular degradation as well as having thepotential for adverse immunological reactions with subsequenttreatments. In one or more embodiments, the chaperone is administered atthe same time as replacement enzyme. In some embodiments, the chaperoneis co-formulated with the replacement enzyme.

Reference throughout this specification to “one embodiment,” “certainembodiments,” “various embodiments,” “one or more embodiments” or “anembodiment” means that a particular feature, structure, material, orcharacteristic described in connection with the embodiment is includedin at least one embodiment of the invention. Thus, the appearances ofthe phrases such as “in one or more embodiments,” “in certainembodiments,” “in various embodiments,” “in one embodiment” or “in anembodiment” in various places throughout this specification are notnecessarily referring to the same embodiment of the invention.Furthermore, the particular features, structures, materials, orcharacteristics may be combined in any suitable manner in one or moreembodiments.

Although the invention herein has been described with reference toparticular embodiments, it is to be understood that these embodimentsare merely illustrative of the principles and applications of thepresent invention. It will be apparent to those skilled in the art thatvarious modifications and variations can be made to the method andapparatus of the present invention without departing from the spirit andscope of the invention. Thus, it is intended that the present inventioninclude modifications and variations that are within the scope of theappended claims and their equivalents.

EXAMPLES Example 1: Effect of DGJ on G9331A Mutation

The effect of DGJ in a male Fabry lymphoblast line with confirmedpresence of the G9331A GLA mutation was studied to determine themagnitude and EC₅₀ values. G9331A or normal human (positive control)lymphoblasts were seeded at 25,000 cells per well (in 96-well plates).The lymphoblasts were then incubated±DGJ (10-pointconcentration-response curves) for 5 days. The concentration range forboth cell lines was 5 nM to 100 μM. The α-Gal A activity in cell lysateswas measured using the 4-MUG synthetic fluorogenic substrate. Maximumlevels in the presence of DGJ are defined as the top of the sigmoidalconcentration -response curve. It was then determined if α-Gal A levelswere increased in response to DGJ. Enzyme assay results were confirmedby western blot.

FIGS. 4 and 5 show representative α-Gal A activity data in mutant andnormal lymphoblasts, respectively. As seen in the figures, both theG9331A and normal positive control lymphoblasts showconcentration-dependent increased levels in response to DGJ. Data pointsare the mean±SEM of quadruplicate determinations. The data represent theresults of four independent experiments.

A summary of the α-Gal A activity is shown in Table 1 below.

TABLE 1 Lymphoblast α-Gal A activity data summary Relative −DGJ +DGJ %of WT Increase α-Gal A % of α-Gal A % of Relative EC₅₀ @ 10 μM @ 10 μMCell Line N activity WT activity WT Increase (μM) DGJ^(#) DGJ^(#) T-testNormal 4  36 ± 6 100 ± 0 58 ± 7  167 ± 10 1.6 ± 0.1*** 0.52 ± 0.2 1641.6 0.0008 G9331A 4 6.2 ± 1  19 ± 5 9.8 ± 1.2 31 ± 6 1.6 ± 0.2*  0.63 ±0.3 30 1.6 0.0155 α-Gal A activity, nmol/mg protein/hr; % of WT, percentof wild-type α-Gal A activity without AT1001; Columns with the symbol“^(#)” indicate that the values at 10 μM AT1001 are calculated based onthe measured baseline, maximum and EC₅₀ values using a sigmoidalconcentration-response equation that assumes a Hill slope of 1 (maximumlevels in the presence of AT1001 are defined as the top of the sigmoidalconcentration-response curve); *p < 0.05, **p < 0.01, ***p < 0.001 bytwo-tailed, paired t-test comparing baseline and maximum α-Gal Aactivity.

As shown in Table 1, for this ‘leaky splice site’ mutation, the G9331Alymphoblasts have lower than normal baseline α-Gal A activity. Howeverthe maximum relative increase and EC₅₀ value are virtually equivalent tothose of normal lymphoblasts. In addition, significant increases inα-Gal A protein levels, similar to those of normal lymphoblasts, wereseen in response to DGJ incubation of this Fabry cell line (G9331A,2.1±0.5-fold, n=3; Wild Type, 1.8±0.1-fold, n=6). The results from theIVS4+919G→A lymphoblasts meet the HEK -293 cell criteria for an‘eligible mutation’: α-Gal A mutant forms with a relative increase thatis 1.2-fold above baseline and an absolute increase that is ≥3% ofwild-type after incubation with 10 μM DGJ.

Western blot data was used to confirm the previous results. 40 μg lysatewas loaded per lane. Representative Western blot data of the G9331Alymphoblasts is shown in FIG. 6. As seen in the figure, the Western blotdemonstrated an increase in α-Gal A protein of ˜1.68-fold afterincubation with 1 mM DGJ. This data represent the results of fourindependent experiments.

Example 2: Verification of G9331 Mutation

The presence of G9331A was confirmed in the cell line by sequencing. A1000-bp fragment surrounding the site of the IVS4+919G→A mutation wasPCR amplified from genomic DNA isolated from the mutant (tested twodifferent cultures) or normal human lymphoblasts (wild-type). Eachfragment was sequenced (Genewiz), and the presence of the IVS4+919G→Amutation was confirmed in both lots of G9331A cells whereas thewild-type sequence was confirmed in the normal cells.

Example 3: Verification of Absence of Wild-Type GLA in G9331Lymphoblasts

Next, it was verified that the wild-type GLA gene is not present in thetested mutant lymphoblasts. Three separate strategies were used todemonstrate that the wild-type GLA gene is not present in the G9331Alymphoblasts. In all three strategies, G9331A lymphoblast samples werecompared to those of wild-type lymphoblasts and a 1:1 G9331A :wild-typemixture. Samples from wild-type lymphoblasts were used as a control toshow that the method is sensitive for detection of the pure wild-typegene. Samples from the mixture of mutant and wild-type lymphoblasts wereused as a control to show that the method is sensitive for detection ofthe wild-type gene at a level expected from a heterozygous female(because no female G9331A lymphoblasts are available)

Strategy 1: PCR Amplification of a Y Chromosome-Specific Gene

Under this strategy, absence of wild-type GLA is confirmed if the cellline is from a male. If the cell line is from a male, then only themutant allele can be present. SRY (sex -determining region Y, 614-bp;ACC#L08063) was chosen as the Y chromosome-specific gene to PCR amplify.SRY was readily amplified from the IVS4+919G→A lymphoblasts (FB-11 celllines), indicating that the genomic DNA from these cells contains a Ychromosome. SRY was also readily amplified from wild-type lymphoblasts(wild-type cell line) and from a 1:1 mixture of genomic DNA from the twocell lines, indicating that the wild-type genomic DNA also contains a Ychromosome. The results of this experiment are shown in FIG. 7, wherethe presence of SRY in all three samples is clearly shown. In summary,these results indicate that the IVS4+919G→A lymphoblast cell line ismale

Strategy 2: Demonstrate the Absence of a Bfa I Restriction Site atG9331A

In this strategy, the absence of a Bfa I restriction site at G9331A in aPCR -amplified fragment of genomic DNA indicates absence of wild-typeGLA gene. The G9331A mutation disrupts a Bfa I cleavage site that ispresent in the wild-type GLA gene (see Ishii et al, Am J Hum Genet70:994-1002, 2002).

A 334-bp PCR fragment surrounding IVS4+919 was amplified fromlymphoblast genomic DNA, digested with Bfa I, and analyzed by agarosegel electrophoresis. A G→A transition mutation at IVS4+919 removes a BfaI recognition site. If wild-type GLA is present, then three bands areexpected (334, 122 and 212 bp). If IVS4+919G→A is present, then only oneband is expected (334 bp).

The results are shown in FIG. 8. As shown in the figure, Bfa I digestionwas detected in samples from control wild-type lymphoblasts and from a1:1 mixture of genomic DNA from the two cell lines. No Bfa I digestionwas detected in IVS4+919G→A lymphoblasts, indicating that no wild-typeGLA gene was present in the genomic DNA of these cells.

Strategy 3: Show Optimal Sequencing Results That Indicate the PurePresence of G9331A

Using this strategy, optimal sequencing results are generated thatclearly show the pure presence of the mutant “A” nucleotide without anyhint of the wild-type “G.” First, a 1962 bp PCR-fragment was amplifiedfrom lymphoblast genomic DNA using gene-specific primers and highfidelity polymerase, Next, a 721 bp PCR-fragment was amplified usinginternal primers within the 1962 bp fragment. Three PCR samples weresent to GeneWiz for DNA sequencing. The results, shown in FIG. 9,suggest that only “A” is present in the sample, only “G” is present inthe wild-type sample, and both “A” and “G” are present in the mixedsample This suggests that no wild-type GLA gene is present in thegenomic DNA of IVS4+919G→A lymphoblasts

SUMMARY AND CONCLUSIONS

As shown in the above examples, the α-Gal A activity assessed in theassay and by western blots show that α-Gal A levels are increased inresponse to DGJ in G9331A lymphoblasts. Further, the magnitude of theresponse to DGJ meets the Fabry pharmacogenetic reference table criteriafor an “eligible mutation.” Further, the response was confirmed to besolely from α-Gal A produced from IVS4+919G→A GLA, as the cells wereshown to be male and no evidence of a wild-type GLA allele was detectedfrom the genomic DNA in these cells. This shows that cells with theG9331A splice site mutation will respond to treatment with chaperone,and therefore Fabry patients with this genotype may be selected fortreatment with DGJ.

What is claimed is:
 1. A method of treating a patient diagnosed withFabry disease, the method comprising administering to the patient atherapeutically effective dose of 1-deoxygalactonojirimycin or saltthereof, wherein the patient has a splice site mutation in intron 4 ofthe nucleic acid sequence encoding α-galactosidase A.
 2. The method ofclaim 1, wherein the mutation is relative to SEQ ID NO:
 1. 3. The methodof claim 1, wherein the mutation is G9331A relative to SEQ ID NO:
 1. 4.The method of claim 1, wherein the dose of 1-deoxygalactonojirimycin orsalt thereof is from about 25 mg to about 250 mg.
 5. The method of claim1, wherein the salt of 1-deoxygalactonojirimycin is1-deoxygalactonojirimycin hydrochloride.
 6. The method of claim 1,wherein the dose is about 150 mg every other day of1-deoxygalactonojirimycin hydrochloride or an equivalent dose of1-deoxygalactonojirimycin or a salt thereof other than the hydrochloridesalt.
 7. The method of claim 1, wherein the 1-deoxygalactonojirimycin orsalt thereof is administered orally.
 8. The method of claim 1, whereinthe 1-deoxygalactonojirimycin or salt thereof is administered byinjection.
 9. The method of claim 1, where in the patient is male. 10.The method of claim 1, where in the patient is female.
 11. A method oftreating a human patient diagnosed with Fabry disease, the methodcomprising administering to the patient a therapeutically effective doseof 1-deoxygalactonojirimycin or salt thereof, wherein the patient has asplice site mutation in intron 4 of the nucleic acid sequence encodingα-galactosidase A, and wherein the dose is about 25 to about 250 mgevery other day of 1-deoxygalactonojirimycin hydrochloride, or anequivalent dose of 1-deoxygalactonojirimycin or a salt thereof otherthan the hydrochloride salt.
 12. The method of claim 11, wherein themutation is relative to SEQ ID NO:
 1. 13. The method of claim 11,wherein the mutation is G9331A relative to SEQ ID NO:
 1. 14. The methodof claim 11, wherein the dose is about 150 mg every other day of1-deoxygalactonojirimycin hydrochloride or an equivalent dose of1-deoxygalactonojirimycin or a salt thereof other than the hydrochloridesalt.
 15. The method of claim 11, wherein the salt of1-deoxygalactonojirimycin is 1-deoxygalactonojirimycin hydrochloride.16. The method of claim 11, wherein the 1-deoxygalactonojirimycin orsalt thereof is administered orally.
 17. The method of claim 11, whereinthe 1-deoxygalactonojirimycin or salt thereof is administered byinjection.
 18. The method of claim 11, where in the patient is male. 19.The method of claim 11, where in the patient is female.